=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124382221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIVID EYE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2012
-----------------------------------------------------
Last Update Date | 07/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5355 W LOOP 1604 N
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78253-7300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-379-7853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5355 W LOOP 1604 N
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78253-7300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-379-7853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. NEGIN NOOSHIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-379-7853
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TX7223TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------